The main purpose of this paper is to explain the patterns of access to water supply and sanitation facilities in urban areas in Sub-Saharan Africa since the late 90's, and its relation with the performance of service providers in the case of improved water supply. It also seeks to explore the institutional context of the water supply and sanitation sectors. The paper concludes that services providers in Sub-Saharan Africa have been unable to keep up with urban population growth. Service providers are overwhelmed by the pace of urban population growth as they face high distributional losses, low billing collection, overstaffing, and under recovery of costs. The institutional frameworks are yet to be completed as there is vast political inference in service provision and regulation, as well as obstacles for effectively undertake public private partnerships. The paper is organized as follows. Section one presents definitions of water supply sources and sanitation, as well as the sources of data used for the analysis. Section two discusses the current and projected trends of urbanization, and introduces the country clustering used for analytical purposes. Section three and four present pathways of access to water supply sources and sanitation facilities -respectively- in urban areas in Sub-Saharan Africa, and discusses trends in access by country cluster. Section five explains the operational and financial performance of services providers in the region. Section six explores the existing institutional arrangements for the urban water supply and sanitation service provision. Finally, section six presents the main challenges for the future expansion of sustainable improved water supply and sanitation services.